Forty Years Later: Let's Not Be Gender Blind
Women in Global Health (WGH) strongly supports the commitment made by world leaders in in the Declaration of Alma-Ata 1978 to achieve health for all through Primary Health Care (PHC). We believe that the commitment to Universal Health Coverage (UHC), agreed to by world leaders in the 2015 Sustainable Development Goals (SDG 3, Target 3.8), is the visionary goal that can deliver health for all.
PHC and UHC are mutually reinforcing. PHC is essential to meeting the right to health for all people everywhere and therefore essential to achieving UHC. In turn, UHC rests on the foundation of effective and equitable PHC. WGH therefore applauds the resolve expressed in the draft Astana Declaration to reaffirm high level political commitment to PHC and confirming PHC as ‘a necessary foundation to achieve UHC.’
However, WGH notes that gender equality will determine the achievement of PHC and UHC for three major reasons.
Firstly, the ‘Universal’ in UHC means that it must reach everyone regardless of gender, ethnicity, caste, income or any other social or personal characteristic. UHC must reach all women and girls everywhere if it is to succeed in leaving no one behind. Success in achieving UHC will be measured by who is included and able to access needed care. Women and girls from disadvantaged social groups will generally be the hardest to reach, not least because on average women have lower incomes than men and less control over money.
As the draft Declaration states: ‘societies do not automatically gravitate toward health and health equity. To be successful, we need to take deliberate actions to reinforce the three components of PHC, emphasizing greater equity, quality and efficiency’. WGH supports this statement. Given the historic political, economic and social marginalization of women and girls in many contexts, deliberate action is needed to address gender equality and the rights of women and girls in both PHC and UHC.
Secondly, to achieve UHC and the SDGs, an estimated 40 million new health and social care jobs will be needed globally by 2030, and an additional 18 million health workers, primarily in low income countries. The majority of these new jobs should be in PHC to meet changing demographics and burden of disease.
Women hold 70% of jobs in the health and social care sector, and are the majority in roles delivering prevention services and care at PHC level. But they are greatly underrepresented in senior and decision-making roles and over represented in lower ranking, less well-paid jobs and sectors.
An investment in UHC requires an investment in women in the health and social care workforce. Governments must address gender equality and invest in women to ensure decent working conditions, particularly for frontline health workers at community level. Women are the backbone of health systems, particularly in PHC but are often underpaid and marginalized. This is inequitable and also weakens health delivery systems, since the health workers who know the most about the health systems they run have the least say in their design and management.
Effective health systems must ensure gender parity at all levels of decision-making to harness women’s perspectives and talent.
Thirdly, both PHC and UHC rest on the unpaid work done by women in social care. Women provide the majority of unpaid care globally for their families and communities, estimated to be worth over $3 billion per annum. Much of this care for children, the disabled, older people and community members is unrecorded.
The burden of this care may fall on girls and interrupt their schooling and future economic opportunities. Similarly, this burden of unpaid care work can keep women in poverty because they are unable to take paid work. Countries implementing UHC must recognize and address the unpaid health care work performed by all genders. It has implications for individuals but also has major negative impacts upon the economy and economic growth.
In addition, WGH want to stress that health is a human right. We cannot cherry-pick certain aspects of rights above others, and expect global health to be equitable and effective.
WGH therefore recommends the Astana Declaration include the following four commitments:
1. Commitment to equity of access to PHC, particularly for the poorest and most marginalized women and girls.
2. Commitment to equality, especially gender equality and addressing the gendered determinants of health, the needs and rights of the female health workforce and the burden of unpaid health and social care that largely falls upon women. Women, as the majority of workers in global health, currently deliver care to around 5 billion people and will deliver both PHC and UHC if enabled to do so.
3. Commitment to invest in the female health and social care workforce. Forty million new health and social care jobs will be created globally by 2030 to reach UHC. An additional 18 million health workers are required to meet the needs of the health workforce, primarily in low-income countries. The majority of these new jobs will be in PHC to meet changing demographics and burden of disease. Globally, women hold over 70% of jobs in the health and social care sector but are greatly underrepresented in senior and decision making roles. We will address gender equality and invest in women to ensure decent working conditions, particularly for frontline PHC workers at community level. We will work with partners in all sectors to ensure gender parity at all levels of decision-making in health to harness talent from the whole of society.
4. Commitment to integrate sexual health and reproductive rights (SRHR) into PHC, as it proves financially sound to integrate contraceptive services and safe abortion practices into PHC, to avoid forcing women into high-risk situations.
Forty years ago, world leaders resolved in the Declaration of Alma-Ata to achieve health for all through PHC. Implementation of that commitment, however, has not been fast or extensive enough. Millions of people die prematurely and suffer every year because they lack access to efficient, affordable and quality PHC. The commitment by world leaders in the SDGs to deliver UHC by 2030 provides a significant opportunity to deliver the Alma-Ata Declaration commitment on PHC within the broader framework of UHC. WGH strongly supports this ambition.
Gender-blind approaches to delivering PHC and UHC will fail because they overlook the gendered determinants of health and the contribution made by women as the majority of the workforce in global health and social care. Women currently make an essential contribution to delivering global health and social care, and are equally essential to delivering PHC and UHC. It is time to change the narrative and recognize women as drivers of change in global health, and not only as beneficiaries.
We urge political leaders and partners in all sectors to invest in PHC now. They must ensure the gender dividend from investing in women’s health and women's work in health and social care. We also urge political leaders and partners to realize the youth dividend and health aging dividend, and prepare today's young populations in low- and middle-income countries to become healthy older populations. By immediately taking action on gender equality, world leaders can ensure this anniversary of Alma-Ata will be different from past anniversaries, and mark serious progress on the road to UHC and health for all.
Women in Global Health